No-Fault Case Law

The relevant facts considered in this case were a motion by the defendant to compel the plaintiff to respond to a demand for a bill of particulars and to produce a witness for examination before trial. The main issues were whether the plaintiff adequately responded to the defendant's bill of particulars and whether the plaintiff's treating physician must appear for an examination before trial. The court held that the responses to the demand for a bill of particulars were sufficient and denied the defendant's motion to strike the plaintiff's complaint for failure to respond. The court also held that, based on relevant case law, the insurance carrier is entitled to an examination before trial of a medical provider in a no-fault case, provided certain conditions are met by the carrier. The court denied the defendant's motion, as the issue of whether the defendant issued a timely denial and the basis for denial of the plaintiff's claim was not addressed by either party.

The court considered the claims brought by Precision Diagnostic Imaging, P.C. to recover $1,791.73 under the No-Fault Law for MRIs that it performed on its assignor, Olga Papirova, and the issues of whether the plaintiff had standing to assert the claim and whether the MRIs were medically necessary. The court granted defendant Travelers Insurance Company's motion for summary judgment on the grounds that it satisfactorily showed that the MRIs were not medically necessary. The court's function on a motion for summary judgment is issue finding, and the defendant had tendered evidence to establish a prima facie case, which shifted the burden to the plaintiff to produce evidentiary proof to establish the existence of material issues of fact. Defendant showed the MRIs were not medically necessary, and plaintiff had not submitted any documentation to establish that the services rendered were medically necessary. The court held that the failure of the medical facility to rebut the insurer's showing that the service provided was not medically necessary requires denial of reimbursement.

The main issues in the case involved an action for recovery of No-Fault Insurance benefits for medical treatment provided on a specific date, and the plaintiff's motion to strike the defendant's Notice of Trial. The defendant had repeatedly failed to respond to the plaintiff's motions. In order for the plaintiff to be entitled to summary judgment in a No-Fault Insurance action, it had to make a prima facie showing that it submitted the appropriate claim forms and that they were received by the insurer. Partial payment had been made and the balance was denied on each claim within the time prescribed by statute. The court found that the denials were ineffectual under the rationale articulated in a previous case, and that the defendant had failed to produce any evidentiary proof of a triable issue of fact requiring a trial. As a result, the plaintiff's motion for summary judgment was granted, and judgment was entered in favor of the plaintiff.

The court considered a case in which medical providers were seeking to recover first party no-fault benefits from an insurance company for treatments provided to an insured patient. The insurance company denied payment for psychotherapy sessions and neurological testing performed on the patient, claiming that the services were not medically necessary. The main issues decided in the case were whether the diagnostic testing and psychotherapy sessions were medically necessary, as defined by the Insurance Law, and whether the insurance company properly denied payment. The court held that the insurance company did not sustain its burden of proof for the lack of medical necessity of the psychotherapy sessions and neurological testing provided to the patient, except for neurological testing redundantly billed on a specific date. As a result, the judgment was entered for the plaintiff in the reduced amount of $3,761.15, plus interest and attorneys' fees as provided by the Insurance Regulations, and the statutory costs and disbursements of the action.

The court considered the claim by A.B. Medical Services PLLC for first-party no-fault benefits from GEICO Casualty Insurance Co. A.B. Medical Services PLLC submitted completed claim forms and established that payment of benefits was overdue. The main issue was whether GEICO provided proof to raise a triable issue of fact regarding the lack of medical necessity of the services rendered. The court held that GEICO failed to provide proof in admissible form to support their defense, and therefore, granted the motion for summary judgment in favor of A.B. Medical Services PLLC in the principal sum of $3,971.20. The court remanded the matter to the lower court for a calculation of statutory interest and an assessment of attorney's fees. The appeal by Somun Acupuncture P.C. and Square Synagogue Transportation Inc. was dismissed.

The case involves an action to recover first-party no-fault benefits for medical equipment furnished to assignors. The plaintiff claimed that it submitted the statutory claim forms, setting forth the fact and amount of the losses sustained, and that payment of no-fault benefits was overdue. The court decided in favor of the plaintiff, holding that the plaintiff established a prima facie entitlement to summary judgment. However, the burden shifted to the defendant to create a triable issue of fact, and it failed to do so. The court noted that proof of mailing or an admission of receipt was lacking, and the defendant failed to create triable issues of fact as to the assignors' alleged failure to comply with the initial and follow-up verification requests. Therefore, the plaintiff's motion for summary judgment was granted, and the case was remanded to the lower court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered a case where a medical services provider, A.B. Medical Services PLLC, was seeking to recover first-party no-fault benefits from Integon National Insurance Company for two tests performed on August 20, 2001 and August 27, 2001. The insurance company denied both claims based on peer reviews that questioned the medical necessity of the tests. Plaintiff moved for summary judgment as to both claims. The court found that the peer reviewer's conclusion regarding the medical necessity of the test performed on August 20, 2001 raised a triable issue of fact, so summary judgment was not granted for that claim. However, there was an evaluation prior to the second test performed on August 27, 2001, and the defendant's basis for denial of that claim lacked merit in fact, so the court granted partial summary judgment in favor of the plaintiff in the principal sum of $1,999.12 and remanded the case for further proceedings.

The court considered the fact that the plaintiff, Ocean Diagnostic Imaging, was seeking to recover $2,670.40 in assigned first-party no-fault benefits for medical treatment rendered to their assignor, Charles Brown. The main issue decided by the court was whether the plaintiff was entitled to summary judgment. The court held that the plaintiff was entitled to summary judgment because they had submitted claims setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The court also found that the defendant's failure to pay or deny the claim within 30 days of receipt precluded the defendant from interposing most defenses. Additionally, the court ruled that the delay letter issued by the defendant did not toll the claim determination period, and that the defendant's examinations under oath requests were ineffective to toll the claim determination period under New York's No-Fault Law. Finally, the court noted that the defendant's claim of a fraudulent application was unsupported by evidence sufficient to create a triable issue of fraud.

The relevant facts in the case involved an action to recover no-fault medical payments under insurance contracts, where New York and Presbyterian Hospital, as assignee of Jorge Peralta, New York Hospital Medical Center of Queens, as assignee of Christopher O'Neill, Mary Immaculate Hospital, as assignee of Racheal Castro, and Nyack Hospital, as assignee of Lourdes Veras, appealed from an order denying their motion for summary judgment on the first cause of action and granting the defendant's cross motion for summary judgment dismissing the first cause of action. The main issue decided by the court was whether the defendant was precluded from asserting the defense of the hospital's untimeliness in this action pursuant to Insurance Law § 5106 (a) for no-fault medical payments, and the holding was that the defendant is precluded from asserting the defense of the hospital's untimeliness in this action pursuant to Insurance Law § 5106 (a) based on the fact that despite the hospital's delay in providing verification of the claim, the defendant failed to either pay or deny the claim as required by 11 NYCRR 65.15 (g) (2) (iii). Therefore, the order denying the plaintiff's motion for summary judgment on the first cause of action was reversed, and the defendant was ordered to pay one bill of costs to the plaintiff New York and Presbyterian Hospital, as assignee of Jorge Peralta.

The relevant facts considered by the court included a health care provider submitting a claim for no-fault benefits for medical services rendered to its assignor, and the insurance company denying the claim more than two months after receiving it. The main issue decided was whether the insurance company's requests for examinations under oath tolled the 30-day claim determination period, and whether the insurance company could assert the defense that the collision was in furtherance of an insurance fraud scheme. The court held that the insurance company's requests for examinations under oath did not toll the claim determination period, but the company could still assert the defense of insurance fraud, despite its untimely denial of the claim, as the denial was based on a "founded belief that the alleged injuries do not arise out of an insured incident." Therefore, the court affirmed the denial of the health care provider's motion for summary judgment.